Claire and Geillis are unceremoniously dropped into the thieves’ hole where they have a bit of time to bond as they await their fate. Claire confronts Geillis about Arthur’s death and Geilis admits that she did poison him with cyanide but only after trying for months to kill him with arsenic!

Indeed, Arthur appears ill every time we see him, suffering from various stomach ailments and discomfort. Even Claire was stumped as to what may have been causing his trouble.

The symptoms were rather puzzling; not like ulcer, I thought, nor cancer- not with that much flesh still on his bones- perhaps just chronic gastritis, as Geilie insisted.

From Outlander by Diana Gabaldon, Chapter 24

But now it is all so clear. Arthur has been suffering the effects of chronic arsenic poisoning all these months.

Arsenic is ubiquitous in the environment, found in ground water most commonly, and also a byproduct of mining and smelting metals. It has been used medicinally for over 2400 years in traditional Chinese medicine and also used to treat syphilis in the western world before the development of penicillin. In the Elizabethan era, women used a mixture of vinegar, chalk and arsenic which they applied to their faces in hopes of preventing aging and creasing of the skin. Arsenic is an ingredient in green pigments used to color most anything – wall paper, textiles, paint.

Arsenic has been a favored poison throughout history. Tasteless and odorless, it was an easy choice. It is particularly known to have been used by the Borgias in Italy and is also thought to have been responsible for the death of Napoleon Bonaparte. In the 19th century, arsenic was dubbed “inheritance powder” because it was suspected that many impatient heirs ensured or accelerated their inheritance by means of poisoning with arsenic.

The most toxic form, white arsenic, or arsenic trioxide, is of course what Geillis chose.

Arsenic poisoning is due to ingestion most often, but also occurs via absorption through the skin and by inhalation. Arsenic is readily taken up by the red blood cells and distributed throughout the body, and is particularly toxic to the gastrointestinal system, kidneys, bone marrow, skin and nervous system.

White arsenic binds to and interferes with numerous enzymes in the cells of the body, wrecking havoc on normal cell function.

Symptoms after acute poisoning develop in minutes to hours and generally begin in the gastrointestinal system causing nausea, vomiting, abdominal pain and severe watery diarrhea. It can cause a garlic odor on the breath and in the stool. Severe poisoning leads to abnormal heart rhythm, shock, acute respiratory distress and death.

What Arthur suffered, however, is chronic toxicity – long term exposure of lower levels of arsenic. The symptoms come on more slowly but still have significant consequences. Chronic exposure leads to abdominal pain, nausea and diarrhea as well, but also skin lesions, peripheral neuropathy (numbness and tingling, then intense burning pain to the hands and feet), cancer of the skin, bladder, lungs and liver, type 2 diabetes, and respiratory problems.

We’ve witnessed Arthur suffering with abdominal distress just about every time we’ve seen him. He’s been treated with peppermint by Geillis and fennel from Claire for his discomfort. These provide temporary relief but won’t cure him.

But alas, when that doesn’t do poor Arthur in, Geillis employs another technique and Arthur meets his end by cyanide poisoning.

Ah, Geillis, we wanted so much to like you, what with the fabulous red shoes and talk of BBQs…

Ah, the Wedding. Claire and Jamie are in no immediate threat of danger, no one is attacked, there are no poisons, no boar hunts, and aside from the superficial lacerations to the wrists of the bride and groom in the ceremony, no real risk of trauma.

The world’s oldest profession also has a long story of infectious disease to tell! We will hope that Ned came away from his night in the brothel unscathed, and perhaps he has taken some precautions.

Ned Gowan is an educated man and hopefully he made use of the protection available at the time. First documented to be used in Greece around 3000 B.C., early condoms were made of goat bladder and of linen and had not changed dramatically by the time we arrive in the 18th century, though fortunately tortoise shell and horn were no longer popular materials! Condoms of the 18th century were made of either chemically-treated linen or from animal bladder or intestine. It is unclear how widespread their use was, though they were widely sold in pubs and markets in Europe.

Syphilis and gonorrhea were the most prevalent STDs of the time. Syphilis, in particular, has severe, life-changing consequences. Known by a variety of names depending on a person’s geographic locale (everyone blames everyone else!) including “great pox,” “the disease of Naples,” “the Spanish disease,” “the French disease,” “Persian fire,” and called “grandgore” by the Scots, the first documented epidemic of syphilis is among French soldiers in 1495. Symptoms included genital sores, abscesses, and ulcers over the body and severe pain. Remedies were few and of questionable efficacy.

Syphilis is a sexually transmitted infection caused by the bacterium Treponema palladium. The disease occurs in stages and can be very disfiguring and ultimately fatal. The first sign of infection is a skin lesion called a chancre at the location exposed to the bacterium, generally on the genitals. This is classically a single skin ulceration up to 3cm in size and generally painless. Enlargement of the lymph nodes in the area is common. Without treatment, the lesion persists for 3 to 6 weeks.

Approximately 25 percent of untreated patients infected with syphilis will progress to secondary syphillis. This occurs 1-2 months after the primary infection and manifests in many ways. Generally, this involves symptoms of the skin, mucous membranes and lymph nodes including non-itchy rash to the trunk and extremities including the palms of the hands and soles of the feet. Wart-like lesions may develop on mucous membranes. All of these lesions contain the bacteria and are infectious. Fever, sore throat, weight loss, hair loss and headache also occur. Rare complications include liver involvement, kidney disease, joint inflammation, and ocular (eye) abnormalities. These symptoms will last for another 3-6 weeks.

Approximately 30-60% of those who are exposed to the wounds of someone with primary or secondary syphilis will contract the disease. The bacteria die very quickly outside of the body so transmission from objects like toilet seats, hot tubs, sharing utensils, is not thought to be possible.

Syphilis can then enter a latent phase in which there are no symptoms of the disease but blood testing will still prove infection is present.

Without treatment, one third of people infected with syphilis will develop tertiary syphilis with devastating consequences. Chronic gummas, or soft, tumor-like balls of inflammation occur in the skin, bone and liver. Syphilis can infect the heart and vascular system, leading to aortic aneurysms among other complications. Infection of the nervous system (neurosyphilis ) results in meningitis, general paresis (a progressive severe dementia along with difficulty moving the muscles of the face and limbs) and tabes dorsalis – a disease of the spinal cord leading to severe pain, impaired sensation and bladder dysfunction.

Syphilis can be transmitted from mother to child during pregnancy or childbirth and can result in stillbirth, prematurity and a number of severe and disabling symptoms including deformity of the face and teeth, bony deformity and deafness. Women who receive prenatal care are tested for spyhilis during pregnancy and treatment with antibiotics can eradicate it. Congenital syphilis, however, does remain a problem in developing countries where prenatal care is not readily available.

Portrait of Gerard de Lairesse by Rembrandt van Riin, circa 1665-67. de Lairesse had congenital syphilis leading to deformity of his face and eventual blindness. (source)

Until the 20th century, mercury was the primary treatment for syphilis – either taken orally or made into ointment and rubbed onto the skin. Mercury, unfortunately, has many toxic side effects: kidney failure, severe mouth ulcers, loss of teeth, neurologic damage and even death. The cure was deemed by some to be worse than the syphilis itself: “A night with Venus and a lifetime with mercury!”

Ultimately, it was the discovery of penicillin by Scottish scientist and Nobel laureate Alexander Fleming in 1928 that would ultimately provide the cure. In 1943, physicians at the US Marine Hospital in Staten Island, NY, proved the effectiveness of penicillin on syphilis and cured infected soldiers with intramuscular injections of penicillin.

Alexander Fleming, who is credited with discovering penicillin in 1928. (source)

The total number of cases of syphilis in the US was 575,593 in 1943, the year penicillin was proven to be effective for syphilis. This dropped to a low in 2000 of 31,618 cases. However, this has steadily been climbing since 2000 and in 2014 there were 63,450 cases! Why? This article from The Atlantic in December 2015 is a good read and discusses a few of the reasons this may be happening including aps like Tinder facilitating more casual sex, the unfamiliarity of young Americans with the risks of untreated syphilis as it isn’t in the public conscience as it had been in the past, the fear of HIV may be declining from its peak in the 1990s, leading to less use of protection.

There is no vaccine for sphilis. Prevention and early diagnosis is key, as early treatment with antibiotics can prevent the devastating effects of this disease!

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